doubt that occur when patients suffer a serious
complication or die due to a mistake made by
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the clinician, healthcare team or health care
system"
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? A 79 year old Male was on regular dialysis due
to CRF. Once while undergoing dialysis he
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started having SOB. He was admitted to theICU and was managed. Next day he
complained of epigastric pain for which he
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was prescribed antacid, which he received
from his nurse. Only........ It was'nt an antacid,
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it was pancuronium!Objectives
(1)To become familiar with common patient
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safety definitions.(2) To become familiar with the causes of
medical errors.
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(3) To become familiar with the common types
of medical errors.
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(4) To become familiar with recommendationthat help prevent adverse events/medical errors
in the healthcare system.
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Patient Safety Definitions
? Medical error, defined as the failure of a
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planned action to be completed as intendedor the use of a wrong plan to achieve an aim.
? Adverse event, defined as an injury caused by
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medical management rather than by the
underlying disease or condition of the patient.
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? Preventable adverse event, defined as aninjury that could have been avoided as a result
of an error or system design flaw.
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? Ameliorable adverse event, defined as an injury whoseseverity could have been substantial y reduced if
different actions or procedures had been performed or
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followed.
? Negligence, defined as whether the care provided
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failed to meet the standard of care reasonablyexpected of an average physician qualified to take care
of the patient in question.
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? Error of omission, occurs when a necessary procedure
or intervention failed to be performed leading to
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morbidity or mortality to the patient involved.Why do errors happen?
? Al humans make errors: indeed, "the ability to
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make mistakes" al ows human beings to function
? Most of medicine is complex and uncertain
? Most errors result from "the system"--inadequate
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training, long hours, ampoules that look the same,
lack of checks, etc
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? Healthcare has not tried to make itself safeEPIDEMIOLOGY
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Epidemiology? Medical errors are the
3rd leading cause of
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death in the US.
? In India, 5.2 million
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medical errors occurannually.
TYPES OF MEDICAL ERRORS
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? Misdiagnosis/delayeddiagnosis/overdiagnosis
? Unnecessary
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tests/procedures? Unnecessary treatment
? Medication errors
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? "Never-events"? Uncoordinated care
? HAIs
? "Not- so- accidental
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accidents"
? Pressure ulcers
? Missed warning signs
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? "Jholachaap" doctors
Failure to provide
prophylactic treatment
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? Failure of
communication
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RISK FACTORS
Risk factors
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? Age? Complexity of care
? Emergency or acute care
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? Insufficient knowledge
? Ignorance of sources of error
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? Low community spirit? Clinician autonomy and low acceptance to
change
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CAUSES? "July effect"
? Poor communication
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? Improperdocumentation
? Illegible handwriting
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? Inadequate nurse topatient ratio
? Cost cutting measures
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? Similarlynamed/sounding
medicines
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? Disconnected reportingsystems in the hospital
? Sleep deprivation
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? Extreme specialization? Logistic problems
? Equipment related
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issues? Unstructured discharge
summaries
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MEDICATION ERRORS
Medication errors
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? There are inherent risks associated with
therapeutic use of drugs.
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? The hazards that result from such risk arecalled drug-misadventuring, which includes
both ADRs and medication error.
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? Episodes in drug misadventuring that should
be preventable through effective systems
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control.TYPES OF MEDICATION ERROR
? Prescribing error
? Omission error
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? Wrong time error
? Unauthorized drug error
? Improper dose error
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? Wrong dosage formerror
? Wrong administration
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technique error
? Deteriorated drug error
? Monitoring error
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? Compliance errorCAUSES OF MEDICATION ERROR
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Causes of medication error? Look alike/sound alike
? Illegible handwriting
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? Inaccurate dose calculation
? Inadequately trained personnel
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? Inappropriate use of abbreviations? Labelling errors
? Excessive workload
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? Medication unavailable
SURGICAL ERROR
? It is a preventable
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mistake during surgery.
Surgical errors go
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beyond the known riskof surgery.
TYPES OF SURGICAL ERROR
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? Nerve injury? Wrong site
? Wrong patient
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? Wrong procedure? Wrong equipment
? Surgical souvenirs!
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? Anaesthesia errors
CAUSES OF SURGICAL ERROR
Insufficient
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Incompetence
preop planning
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ImproperFatigue
surgical
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techniques
Poor
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communicationThe Second Victim
? Is the physician that
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cared for the patient.? Implications for the
second victim: -
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? Emotional and
psychological
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? May result in a careerchange
? May destroy the
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reputation and career
How to think of error?
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? An individual failing? Blaming them for carelessness, forgetfullness
? Wil not solve the problem--Doctors wil
hide errors
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? It is often the best people who make the
worst mistakes
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? Mishaps tend to occur in recurrent patternsHow to think of error?
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? A systems failure? This is the starting point for redesigning the
system and reducing error.
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? Team work
? Better communication
? Evidence based practice
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PREVENTIONINTERNATIONAL PATIENT SAFETY
GOALS(IPSG)
MISCONCEPTIONS
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? "Bad apples" are a common cause- faulty
process of care delivery is more common.
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? High risk procedures are responsible for mostavoidable errors- surgical errors are harder to
conceal, but errors occur at all levels.
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Bottom line
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? Fallibility is part of the human condition? We can't change the human condition but
we can change the conditions under which
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people work.
? Naming, blaming and shaming have no
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remedial value? We need to design health care systems that
put safety first (First, do no harm)
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? These goals highlight problematic areas in healthcare
? Describe evidence-based and expert-based
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consensus solutions
? It is essential that EVERYONE should be familiar
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and able to incorporate into daily practiceIPSG 1-Identify Patients Correctly
Two-fold Intent :
? FIRST, to identify the individual as the person
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for whom the service or treatment is intended.
? SECOND, to match the service or treatment to
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that individual.IPSG 1-Identify Patients Correctly
? Patients must be identified using "two unique
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identifiers" i.e. FULL NAME and CRN
? MUST NEVER use patient's room or location
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to identify patient.? ALWAYS ask the patient / guardian / parent to
verbalize patient's name whenever possible
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IPSG 2- IMPROVE EFFECTIVE
COMMUNICATION
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Verbal medication orders are reserved for code/emergency
situations ONLY.
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? When receiving a medication telephone order from aphysician:
? Nurse A writes the order in the physician order sheet.
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? Nurse B will read back the order written by Nurse A to the
physician.
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? The prescriber will verify the order is correct to Nurse B.? Both Nurse A and Nurse B must document the date and
time the order was received, badge number of the
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prescriber, and their own names, job title and badge
numbers and both must sign the order sheet.
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IPSG 2- IMPROVE EFFECTIVECOMMUNICATION
? Reporting critical results of diagnostic tests.
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? The technologist/reporter wil provide the report to the Receiver
(Requesting Physician/Ward Nurse).
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? The receiver wil document (hand -WRITE) the critical results.? The receiver (or another person - could be another nurse) wil READ
BACK the information provided, including the patient's medical
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record number and name to the reporter.
? The technologists/reporter wil verify the information is correct.
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? Both the reporter and the receiver must document the READ BACKverification procedure was carried out; date and time the report
was received, badge number of the person providing/receiving the
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report.
IPSG 2- IMPROVE EFFECTIVE
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COMMUNICATION
? Handovers of patient care:
? During shift changes
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? Between different levels of care? From in-patient units to diagnostic units
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IPSG 3-Improve the Safety of High-
Alert Medications
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? Medications that pose an increased risk ofcausing significant harm to patients if used in
error.
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? Independent double checks in handling is one
of the safety measures.
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? Look alike & Sound alikeIPSG 4- Ensure Correct-Site, Correct-
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Procedure, Correct-Patient Surgery? UNIVERSAL PROTOCOL:
1.Marking the surgical site
2.Pre-operative verification
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3. Time outMarking the surgical site
? made by the person performing the procedure
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with a permanent skin marker.
? takes place with the patient AWAKE and AWARE,
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if possible.? to be done in al cases involving laterality (right,
left), multiple structures (fingers, toes, lesions) or
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multiple levels or region (spine).
? be done using an instantly recognizable mark
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(ARROW) that is consistent throughout thehospital.
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TIME OUT ? Pause with a purpose? full verification that is performed immediately prior to the
induction of Anaesthesia or the start of an invasive
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procedure
? the entire care team actively and verbally confirms:
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? Patient's identity (two identifiers)? Procedure to be performed
? Correct procedure side/site
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? Necessary imaging, equipment, implants or special
requirements are present
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IPSG 5- Reduce the Risk of HAI? 5 moments of hand hygiene
? Before patient contact
? Before aseptic task
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? After body fluid exposure? After patient contact
? After contact with patient surroundings
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? Wash hands with soap and water when handsare visibly soiled.
? Use alcohol-based hand rub when hands are
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not visibly soiled
IPSG 6- Reduce the Risk of Patient
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Harm Resulting from Falls? Upon initial admission assessment, Physicians
should screen Patient's Functional status
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which include "FALL RISK".
? Functional Screening should be documented in
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the Physicians History and Physical formcomplimented by nurses' assessment.
? Communicate to nurses for implementation.
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SUMMARY
Bottom line
? Fallibility is part of the human condition
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? We can't change the human condition but
we can change the conditions under which
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people work.? Naming, blaming and shaming have no
remedial value
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? We need to design health care systems that
put safety first (First, do no harm)
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MISCONCEPTIONS? "Bad apples" are a common cause- faulty
process of care delivery is more common.
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? High risk procedures are responsible for most
avoidable errors- surgical errors are harder to
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conceal, but errors occur at all levels.--- Content provided by FirstRanker.com ---